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ICD-10-CM TRAINING September 25, 2013

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ICD-10-CM TRAINING September 25, 2013 ICD-10-CM TRAINING September 25, 2013 Obstetrics, Newborn Perinatal and Congenital anomalies Linda Dawson, RHIT, AHIMA Approved ICD-10 Trainer OB Coding Gravida: The term for the state of pregnancy 7] Para: The number of times a female has given birth, counting twins and other multiple births as one pregnancy, and usually including stillbirths. Nulligravida is a woman who has never been pregnant. Primigravida: pregnant for the first time and is referred to as a woman who is (or has been only) pregnant for the first time. Multiparous: Multiple pregnancies Nine code families O00-O08 Pregnancy with abortive outcome O09 Supervision of high risk pregnancy O10-O16 Edema, proteinuria and hypertensive disorders in pregnancy, childbirth and the puerperium O20-O29 Other maternal disorders predominantly related to pregnancy O30-O48 Maternal care related to the fetus and amniotic cavity and possible delivery problems O60-O77 Complications of Labor and Delivery O80-O82 Encounter for delivery O85-O92 Complications predominantly related to the puerperium O94-O9A Other obstetric conditions, not elsewhere classified Code Title Changes ICD-9-CM ICD-10-CM 652 – Malposition and Maternal care for malpresentation of fetus malpresentation of fetus 635 – Legally induced abortion O04 – Complications following (induced) termination of pregnancy Codes moved Legally induced abortion without mention of complication Illegally induced abortion without mention of complication ICD-9-CM ICD-10-CM 635.92 Z33.2 636.92 Code Deleted Breech or other malpresentation successfully converted to Cephalic presentation. ICD-9-CM ICD-10-CM 652.11 O32 Maternal care for malpresentation of fetus. O32.1- Breech - buttocks, frank, complete O32.8- Breech – footling or incomplete Retained POC spontaneous abortion elective termination of pregnancy Multiple codes required for subsequent encounters following a Spontaneous or elective termination of pregnancy. O03 Spontaneous abortion – incomplete or complete 4th-5th digit specify if complete or incomplete and the complication if indicated. or O07.- Failed attempted termination of pregnancy Z33.2 Encounter for elective termination of pregnancy Failed Termination Assign additional codes as necessary to report any complications of pregnancy associated with conditions in category O07 Failed attempted termination of pregnancy category O08 Complications following ectopic and molar pregnancy. O07.0 Genital tract and pelvic infection following failed termination of pregnancy. O35.0XX1 Anencephaly of pregnancy Failed Termination live fetus Z33.2 Encounter for termination of pregnancy Z37.0 Single live birth O09 High Risk pregnancy codes are now in the OB chapter: O09.0- Supervision of pregnancy with history of infertility O09.1- Supervision of pregnancy with history of ectopic and molar pregnancy O09.2- Supervision of pregnancy with other poor reproductive or obstetric history O09.21- History of pre-term labor O09.29- Other poor obstetric history (neonatal death, history of stillbirth) O09.3- Supervision of pregnancy with insufficient prenatal care concealed pregnancy hidden pregnancy O09 High Risk pregnancy codes are now in the OB chapter: O09.4- Supervision of pregnancy with grand multiparity O09.5- Supervision of elderly primigravida and multigravida O09.51- Supervision of elderly primigravida O09.52- Supervision of elderly multigravida O09.6- Supervision of young primigravida and multigravida O09.61- Young primigravida O09.62- Young multigravida O09.7- Supervision of high risk pregnancy due to social problems O09.8- Supervision of other high risk pregnancy O09.81 Pregnancy resulting from assisted reproductive technology (in-vitro) O09.82- History of in utero procedure during previous pregnancy O09.9- Supervision of high risk pregnancy, unspecified Trimester of Pregnancy First: Conception to < 14 weeks 0 days Second: 14 weeks 0 day to < 28 weeks 0 days Third: 28 weeks 0 days until delivery Changes in I-10 Occurrence of care is not an axis in I-10. Instead we include the trimester of pregnancy. 5th or 6th character. 5th character - Trimester is based on the current episode or encounter. Pre-existing conditions Conditions occurring during delivery Trimester of Pregnancy Not all codes required the trimester of pregnancy. O24.4- Gestational diabetes – Specified by “in pregnancy, childbirth and puerperium” If final characters are not applicable to trimester, timeframes of pregnancy are sometimes used. Some codes will not have either trimester, timeframe of pregnancy, as they are specified in category level or do not apply to the code. Trimester of Pregnancy Gestational hypertension – trimester specific: first second third HELLP syndrome – 2nd and 3rd trimester only Pre-eclampsia - 2nd and 3rd trimester only Trimester of Pregnancy Last character of code O42.013 Preterm premature rupture of membranes, onset of labor within 24 hours or rupture – 3rd trimester If the trimester is not a component of a code, the condition is classified to a certain trimester, or not applicable to condition. During the delivery episode, the “in childbirth” option should be used for coexisting condition. O42.013 Preterm PROM, del within 24 hours, 3rd trimester O41.103 Amnionitis in third trimester Preterm labor O60 Definition: Before 37 completed weeks Condition of pregnancy/delivery Categories that do not have terms with pre-existing and pregnancy-related conditions may be used for either. Hypertension during pregnancy When patient has hypertensive heart disease or chronic kidney disease - assign appropriate code from hypertension codes of I11-I13 to further specify the type of hypertensive disease. O10.312 Pre-existing hypertensive heart and CKD complicating pregnancy, 2nd trimester I13.2 Hypertensive heart and CKD with heart failure with stage V CKD or end-stage renal disease I50.21 Acute systolic CHF N18.5 CKD stage V Substance abuse in pregnancy O99.321 Drug abuse in pregnancy, first trimester code first F15.121 Stimulant abuse with intoxication with delirium code drug type Poisonings and Injuries during pregnancy O9A.213 Code the pregnancy related condition first T43.621A Toxic effects of methamphetamine, initial encounter Uncomplicated Pregnancy O80 Minimal or no assistance With or without episiotomy Without fetal manipulation (forceps, rotation or version) Spontaneous cephalic, vaginal, full-term, single, livebirth Not used with any other “O” code Must be “principal diagnosis code” Use delivery code for the appropriate procedure. Use additional code Z37.0 for the single birth Weeks of Gestation Report on every delivery record – Weeks of gestation Z3A Assign as an additional code after complications of pregnancy, childbirth and the puerperium. Report only on maternal record. O76 Abnormality in FHR Z3A.39 39 weeks of gestation Z37.0 Single Livebirth Identification of Affected Fetus 0 – Single gestation Multiple gestation when the fetus is unspecified When it is not clinically possible to determine which fetus is affected. 1 – Fetus 1 2 – Fetus 2 3 – Fetus 3 4 – Fetus 4 5 – Fetus 5 9 – Other fetus A code from O30 must be used for multiple gestations. Identification of Affected Fetus Certain obstetric code categories require a 7th character to identify the affected fetus in a multiple gestation code. Look for instructional note that instructs the coder to assign the 7th character, Breech presentation Transverse presentation O32.2- Face Presentation O32.3- Cephalopelvic Disproportion Compound Presentation O32.6- A 'compound presentation' is the medical term when the baby's hand and arm (or on rare occasions a foot) comes down to lie alongside the baby's head during the pushing phase so that they are born at the same time. (If your baby liked to suck their thumb in the uterus, then they may keep this habit up until they are born) It is more likely to occur when the pelvis is not fully occupied by the fetus because of low birth weight, multiple gestation, polyhydramnios, high presenting part or a large pelvis. Other Malpresentations O32.0- Unstable lie - breech, then vertex, then breech, then transverse, then breech, then vertex. O32.4 - High Head at term Unengaged fetal head New Codes O9A. - Maternal malignant neoplasm, traumatic injuries abuse classified elsewhere but complicating pregnancy, childbirth and the puerperium. O9A.1- Malignant neoplasm complicating pregnancy O9A.2- Injury, poisoning and certain other consequences of external caused complicating pregnancy, childbirth and the puerperium. O9A.3- Physical abuse complicating pregnancy,childbirth and the puerperium New Codes O9A. - Maternal malignant neoplasm, traumatic injuries abuse classified elsewhere but complicating pregnancy, childbirth and the puerperium. O9A.4- Sexual abuse complicating pregnancy, childbirth, and the puerperium O9A.5- Psychological abuse complicating pregnancy, childbirth or the puerperium Combination codes In ICD-9-CM we used two codes to show obstructed labor and the cause of the obstructed labor. In ICD-10-CM we use one combination code. O65.0- Obstructed labor due to fetopelvic disproportion O65.8- Obstructed labor due to other maternal pelvic abnormalities Coding Guidelines Obstetric codes (O) may only be coded on the maternal record. Chapter 15 codes are to be used to report maternal or obstetrical conditions related to, or aggravated by, the pregnancy, childbirth and the puerperium. Code from chapter 15 take precedence over codes from other chapters in the codebook. Notes at the beginning of the chapter or the code block, pertain to all codes within the chapter
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